Posted in BCBS Empire NY, NY Providers, Payers and CPT reinbursement, Pharmacy (Various Insurance Payers), Training, Updates

BCBS Empire NY Medicaid: Reimbursement for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Counseling program

If you are a pediatrician that provides vaccination counseling for patients under 18 years of age and younger then this blog post is for you!

The following is a clarification on the proper coding and billing for or provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.

This reimbursement policy applies to Medicaid members (Empire BCBS).

Note: Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)

The following is the correct CPT code with the ICD-10 code that the providers would use in order to get proper reimbursement.

 CPT® codeFeeNotes
Claims basedCPT 99401DX: Z71.85$12.50A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger.
via Empire BCBS Medicaid Updates

Documentation requirements: In order to get paid for the above mentioned code, the providers need to document the following in either the medical record or a pharmacy record.

  • CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
  • Providers should bill CPT 99402 with ICD-10 code Z71.85.
  • Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
  • Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
  • For more information, visit

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Posted in BCBS Empire NY

BCBS: 32BJ Health Fund Plan- Bariatric Surgery and Joint Replacement Surgery

If you are a surgeon that performs bariatric surgery or joint replacement surgery and see 32BJ Health Fund (BCBS) patients in your office, then this important update is for you! The change will take affect for all surgeries done on DOS 01/01/2022 and thereafter.

32BJ Health Fund has partnered with Hospitals in NY, New Jersey, Connecticut, Massachusetts, Pennsylvania, and Florida to implement a Centers of Excellence (COE) Program for Bariatric and Joint Replacement surgeries.

1.Identifying 32BJ Health Fund patients:

32BJ Health Fund patients are easily identified by the prefix “ETRBJ.”, on their insurance card.

2.Coverage for Bariatric Surgery and Joint Replacement Surgery:

Patients will only be covered if the bariatric surgery and/or joint replacement surgery is performed in one of these COE centers. There will be a $0 copay with a 30 day follow up, after surgery.

32BJ Health Fund patients are NOT COVERED for bariatric and joint replacement surgeries performed by a non-COE provider or at a non-COE hospital.

3.Locating a participating COE provider or COE Hospital:

In order to locate a participating COE provider and a COE Hospital, members need to contact: Plan participants may call 32BJ Member Services at (800) 551-3225.

Providers may call Empire Provider Services at (800) 676-2583.

In addition, 32BJ Health fund patients who live within 50 MILES OF COE Hospital, HAVE to perform their surgery performed by a COE provider at a COE hospital.

(More than 90% of 32BJ members live within 50 miles of a COE hospital.)

More information for Providers:

Any provider looking for more information—particularly anyone currently caring for 32BJ plan participants who may be candidates for bariatric or joint replacement surgery—should call Empire Provider Services at 1-800-676-2583.

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Posted in BCBS Empire NY, Training, Updates

BCBS NY: reimbursement policy for Sexually transmitted infections testing.

In this blog post we will look at the new Reimbursement policy that BCBS NY is applying to billing (professional portion) for sexually transmitted infections testing.

Effective 12/01/2021 and thereafter when the provider orders multiple tests- 87491, 87591, and 87661 on the same day and by the same provider; BCBS of NY will consider these tests as part of a group panel grouping and WILL NOT Reimburse these codes separately.

These codes will be bundled together into a more comprehensive panel testing code: 87801.


87801-Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique.

Reimbursement of 87801:

BCBS of NY will only reimburse ONE (1) unit for code 87801- no matter how many units was billed on the claim.

The provider is required to bill the other STI CPT codes as rendered. Modifiers WILL NOT override this reimbursement policy.

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